ACR: Cut-Off of RA Drugs Before Surgery Arbitrary

Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Note that in this retrospective study of patients with rheumatoid arthritis, the use of anti-TNF medication which was stopped several weeks before joint replacement, was not associated with a significant increased risk of short-term adverse postoperative events.

Note that although there was a trend toward an increase in disease flares within one month after the procedure in patients whose medication was stopped preprocedure, it did not reach significance.

CHICAGO – When patients with rheumatoid arthritis are scheduled for orthopedic surgery, crucial anti-tumor necrosis factor inhibitors are stopped for periods that may be longer than necessary – exposing patients to the risk of disease flares, researchers found.

For example, the average stop time advocated for patients on etanercept (Enbrel) was 2.4 weeks – even though the drug has a half-life of three to 5.5 days, Lisa Mandl, MD, of the Hospital for Special Surgery in New York City, said here.

In her presentation at the annual meeting of the American College of Rheumatology, Mandl also noted that the average stop time ordered for patients on adalimumab (Humira) was 4.6 weeks, despite the half-life of the drug being 1.4 to 2.9 weeks.

Among patients treated with infliximab (Remicade) which has a half-life of one to 1.7 weeks, the average stop time was 4.9 weeks.

"We need to do more studies to see if more pharmacologically-based timing for holding these drugs might potentially decrease rates of postoperative flares," Mandl said.

Mandl and colleagues reviewed cases in the Hospital for Special Surgery's Total Joint Replacement Registry, identifying patients who underwent total knee replacement surgery between June 2007 and May 2010. They found 194 patients with rheumatoid arthritis, including 86 who were treated with anti-tumor necrosis factor drugs.

Physicians had recorded in the charts that the drugs should be withheld in 86% of the cases, and in 74% of the cases the physicians had cited specific stop times.

The researchers found that patients who had been taking anti-tumor necrosis factor inhibitors that had been stopped before surgery were more likely to report disease flares within one month after the procedure than were patients who had not been on the drugs (22.4% versus 16.9%).

That difference was not statistically significant (P=0.47), Mandl acknowledged, but said that larger studies should be done to see if pharmacologically based timing would minimize flares.

The review showed no difference in adverse events -- surgical site infection, pulmonary embolism, deep vein thrombosis, pneumonia, any other infection, or re-operation -- at six months.

"At least in this relatively small sample, it doesn't look like there are any increases in infections or blood clots or other problems that go along with the anti-tumor necrosis factor inhibitors, which is comforting for patients who are on these drugs who are going in for surgery," she said.

"The problem we have with surgery is that there are no studies that have really looked at when we should stop these drugs," said Eric Matteson, MD, chairman of rheumatology at the Mayo Clinic College of Medicine, Rochester, Minn.

He noted that this study is suggesting that stop times be based on pharmacokinetics of the drugs – namely their half lives. "But we probably need to look at the pharmacodynamics of these drugs, which may have longer effectiveness times than their half-life, or it could be less," he explained. "We really don't know the answer because the studies have not been done. And I am not aware of studies that are being done to resolve the issue."

In the Hospital for Special Surgery study, the mean age of the patients with rheumatoid arthritis in their database who were undergoing surgery was 61.7 years; about 87% were women; about 79% were white.

The majority of the patients (59.3%) were being treated with etanercept; 20.9% were on adalimumab; 18.6% were on infliximab, and 1.2% had received golimumab (Simponi).

Mandl had no disclosures. A co-author disclosed commercial interest with Johnson & Johnson.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.